MEDICARE: BULL ST. DISTRICT FAMILY PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1265232326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BULL ST. DISTRICT FAMILY PRACTICE LLC

Provider Business Mailing Address
First Line	:	PO BOX 99
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29202-0099
Country	:	US
Telephone Number	:	803-915-0469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 GREGG ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3527
Country	:	US
Telephone Number	:	803-915-0469
Fax Number	:

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	DR. CORNELL MAURICE CLARK
Credential	:	M.D.
Telephone Number	:	702-904-4077

Provider Enumeration Date	:	03/18/2025
Last Update Date	:	03/18/2025

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